Posts Tagged ‘croup’

Croup treatment has and hasn’t changed

December 21, 2017

With a cough like the bark of a seal
And the kiddy so good doesn’t feel
There’s no way to avoid
A dose of steroid
Croup must be treated with zeal.


Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. A month in the Arctic followed a month in Iowa followed 3 months in British Columbia, to which we have returned. Any identifiable patient information has been included with permission.
I had cause to contemplate how things do and don’t change in medicine. Consider, for example, croup. If a virus swells a child’s narrow airway, a barking cough, much like a seal asking for a fish, follows. Death can ensue if the airway narrows to the point of closing, or if the child stops breathing out of exhaustion.
The pediatric ward in the hospital where I did my residency had two outdated features for treating croup when I arrived.
One consisted of a tiled room that could be filled with water vapor; a large cloud chamber that could sleep 8. During my tenure its only use was storage.
But the spacious balcony on the other side of the nurses’ station told a different story. It had sliding glass doors and space for 6 cribs. In a bad croup year, the nurses bundled the children up, to sleep with their faces uncovered in the cold, dry Wyoming air.
It worked for most of the kids, and I still recommend that strategy, saying, “Now if the spasm of croup doesn’t clear in 3 breaths you’re already headed to the ER.”
Treatments have come and gone and come back. Antibiotics, we found, did no good. Theophylline (a close cousin of caffeine, and found in pharmacologic amounts in chocolate) helped, but not much, and had a lot of side effects so has since been completely displaced by the albuterol (in Canada, salbutamol) updraft.
Every winter, during the peak croup season, I’d ask my pediatrician friends if we’d gotten anything new for croup, and every winter they’d shake their heads.
We used to use inhaled adrenaline (also called epinephrine). It has come and gone in five year cycles. A year and a half ago I thought for sure that I’d never use it again when I heard a study showed it did no better than inhaling saline (salt water).
We used steroids a lot and stopped for a while in the 90s, started again just before the millennium, and continue to this day. Controversy remains regarding dose, and method of administration.
But croup has changed. The really, really bad version, where the epiglottis (the flap valve between the airway and the swallow tube) swells has disappeared with modern immunizations for diphtheria and Hemophilus influenza. And with the decreasing smoking rates we don’t see nearly as much as we used to.
I had cause to research croup treatment recently, finding, to my surprise, that all my internet sources recommend inhaled epinephrine and steroids. Just like 1982.

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Scenes from a weekend on call

September 29, 2013

The weekend covers days three

And guess who’s on call?  It is me!

With period and comma

I document drama

You wouldn’t believe the stuff that I see.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time, 54 hour a week position with a Community Health Center.  I’m just back from a working vacation in Petersburg, Alaska.

Scenes from a weekend on call

Saturday Morning

I sit in a hospital room with a new admit and I take a history.  Sunlight streams through the window, the first day of fall gleams outside with perfect temperature.  When I get to my 84-question Review of Systems, where I ask about every conceivable symptom, violence from the next room shatters the mood.  A domestic disturbance has broken out in the adjacent room and spilled into the hallway along with items of furniture and things that can be thrown.  A mother hurries away with an 8-year-old in tow.  I read the child’s face and the look of wonder and awe, and I see he has been handed a script loaded with dysfunction.  Overcoming what he accepts as normal will take intelligence, persistence, insight, determination, optimism, and, probably, help.

Saturday Morning

I sit beside the patient’s bed.  “What do you think the CT showed?” I ask.

“I don’t know.”

“Do you want to guess?”

“I don’t know.”

The patient knows, and I know it.  I make small talk and then start the trip around the track again.  “What do you think the CT showed?”

After four laps I get the patient to say “cancer.”

Saturday Afternoon

“Yeah, I know I got cirrhosis and I know I should quit drinking but hey, you know, I was about oh I don’t know probably about 3 or 4 weeks and I hadn’t had a drink then, oh I  don’t know, I got pretty hammered.  But I didn’t do it that much and I only did it a couple of times.  And sometimes, geez since July I blow up and then I’ll pee off like about 25 pounds and it comes and goes and now my belly hurts up here on the right.”

 

Saturday Afternoon

“I think she has decided to die.”  The patient’s children look at each other and their faces carry nuance beyond description.

“We kinda thought that since we read that book.”  They refer to Love, Medicine, and Miracles.

 

Sunday Morning

“I gotta be outta here tomorrow for a court appearance.”

I nod.  I have a patient with a heart attack waiting for me in the ER across town and I need to move.  “So how are things going for you?”

“MM?”

“You know, life in general.”

“Real good.”

“Do you really believe that?  When you just told me you girlfriend left with your kid and you have a court appearance?”

“Yeah.  (pause) Well, no.  No.  I got a country and western song in my head.  It’s my life.”

Sunday Evening

It’s past midnight and I’m talking to a judge by phone.  I explain that the patient’s brain function, loosely connected by an accident of genetics, has not improved with a major electrolyte imbalance occasioned by and coincident with severe hypothyroidism and failure to take meds as prescribed by a psychiatrist and endocrinologist.  After non-stop clinical work starting 19 hours previous I can remember the patient’s name and age but not birthdate.  I can, however, relate details about the request for hospitalization, docility in the ER and a quiet hour on the medical floor followed by increasingly loud, bizarre, and violent behavior over the subsequent 2 hours (which responded temporarily to 1 mg of Haldol, but which will necessitate a 48 hour court hold).  The call takes twenty minutes and ends at 1:30.  Vigilance robs my sleep for the next 3 1/2 hours and then I get up, shower, eat, and start rounds again.